Nokea
A client who had a laryngectomy is nearly ready for discharge. Which instruction is most appropriate for the nurse to give?
- A. Always be sure you have a buddy with you when you go swimming or boating.'
- B. You may take a tub bath, but you should not take a shower.'
- C. Be sure to have only liquids for another three weeks.'
- D. Never cover your stoma with anything.'
Correct Answer: A
Rationale: A buddy is essential during swimming or boating to ensure safety, as water entering the stoma can cause aspiration.
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The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement?
- A. Praise the UAP because this prevents the client from tripping on the oxygen tubing.
- B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
- C. Explain to the UAP in front of the client oxygen must be left in place at all times.
- D. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
Correct Answer: B
Rationale: COPD clients need continuous oxygen; replacing it (B) corrects the error safely. Praising (A) is incorrect, explaining in front of client (C) is unprofessional, and escalating (D) is premature.
Which question is essential for the nurse to ask before administering the influenza vaccine?
- A. Have you had influenza in the last year?
- B. Did you receive pneumonia vaccine last year?
- C. Are you allergic to eggs or egg products?
- D. Do you have a history of respiratory disease?
Correct Answer: C
Rationale: Influenza vaccines are often produced using eggs, so an egg allergy must be assessed to prevent allergic reactions.
A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's?
- A. hearing
- B. mental status
- C. vitamin B6 level
- D. vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to vision changes. The nurse must prioritize assessing the patient's vision to detect this side effect early.
If the client identifies that lunches often include the following foods, which meal is the most nutritious?
- A. Tossed salad, rice, and iced tea
- B. Apple sandwich on whole wheat bread and coffee
- C. Meatless chili with beans, corn bread, and milk
- D. Chicken soup, gelatin, and sweetened lemonade
Correct Answer: C
Rationale: Meatless chili with beans, corn bread, and milk provides protein, carbohydrates, and calcium, making it the most balanced and nutritious option.
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
- A. Confirm that the ventilator settings are correct.
- B. Verify that the ventilator alarms are functioning properly.
- C. Assess the respiratory status and pulse oximeter reading.
- D. Monitor the client's arterial blood gas results.
Correct Answer: C
Rationale: Assessing respiratory status and SpO2 (C) ensures immediate patient stability. Ventilator settings (A), alarms (B), and ABGs (D) follow.